Objective  To identify the risk factors and investigate etiological spectrum of pulmonary fungal infections (PFIs) in patients with end-stage liver disease (ESLD).

Methods  A retrospective analysis was performed on the clinical data of 211 ESLD patients. Based on pulmonary imaging, clinical manifestations, and microbiological test results, patients were categorized into three groups, including the PFI group (or the case group), the non-fungal pneumonia group (or the control group 1), and the group without pneumonia (or the control group 2). The clinical characteristics of patients in the the case group were then compared with those of patients in the two control groups. Taking patients without pneumonia as the control, univariate and multivariate logistic regression analyses were performed to identify independent risk factors for PFI, and a nomogram prediction model was constructed based on these risk factors.

Results  Among the 211 patients, 76 (36.1%) had PFIs, 46 (21.8%) had non-fungal pneumonia, and 89 (42.2%) did not have pneumonia. According to findings from the multivariate logistic regression, elevated white blood cell count upon admission (OR = 1.211; 95% CI, 1.011-1.460), higher Model for End-Stage Liver Disease-Sodium (MELD-Na) score (OR = 1.140; 95% CI, 1.021-1.282), concomitant hepatorenal syndrome (OR = 4.150; 95% CI, 1.050-17.300), cumulative glucocorticoid use for more than seven days (OR = 26.832; 95% CI, 6.361-113.221), and the administration of broad-spectrum antibiotics at the time of hospital admission (OR = 6.601; 95% CI, 1.951-22.362) were identified as independent risk factors for PFI. A predictive nomogram model named TJLFPFI was constructed based on these risk factors. The area under the receiver operating characteristic (AUC) curve of the model was 0.899 (95% CI, 0.853-0.945). Etiologic analysis of the 76 PFI cases revealed that 36 (47.4%) had positive results for culture, while 40 (52.6%) had negative results for sputum culture but tested positive by the 1,3-β-D-glucan test and/or galactomannan test. Aspergillus was the most frequently identified pathogen, detected in 25 of the 36 cases (59.5%).

Conclusion  PFI in ESLD patients is closely associated with disease severity at admission, early use of broad-spectrum antibiotics, and prolonged glucocorticoid therapy. Aspergillus is the predominant pathogen. The TJLFPFI model shows potential value in identifying high-risk patients, but prospective validation is still warranted.